Respectful maternity care interventions to address women mistreatment in childbirth: What has been done?

Introduction Over the last decade, there has been an increasing number of studies regarding experiences of mistreatment, disrespect and abuse (D&A) during facility-based childbirth. These negative experiences during labour have been proven to create a barrier for seeking both facility-based childbirth and postnatal health care, as well as increasing severe postpartum depression among the women who experienced them. This constitutes a serious violation of human rights. However, few studies have carried out specifically designed interventions to reduce these practices. The aim of this scoping review is to synthetise available evidence on this subject, and to identify initiatives that have succeeded in reducing the mistreatment, D&A that women suffer during childbirth in health facilities. Methods A PubMed search of the published literature was conducted, and all original studies evaluating the efficacy of any type of intervention specifically designed to reduce these negative experiences and promote RMC were selected. Results Ten articles were included in this review. Eight studies were conducted in Africa, one in Mexico, and the other in the U.S. Five carried out a before-and-after study, three used mixed-methods, one was a comparative study between birth centres, and another was a quasi-experimental study. The most common feature was the inclusion of some sort of RMC training for providers at the intervention centre, which led to the conclusion that this training resulted in an improvement in the care received by the women in childbirth. Other strategies explored by a small number of articles were open maternity days, clinical checklists, wall posters and constant user feedback. Discussion These results indicate that there are promising interventions to reduce D&A and promote RMC for women during childbirth in health facilities. RMC training for providers stands as the most proven strategy, and the results suggest that it improves the experiences of care received by women in labour. Conclusion The specific types of training and the different initiatives that complement them should be evaluated through further scientific research, and health institutions should implement RMC interventions that apply these strategies to ensure human rights-based maternity care for women giving birth in health facilities around the world.


Introduction
Over the last decade, there has been an increasing number of studies worldwide regarding experiences of mistreatment, disrespect and abuse (D&A) during facility-based childbirth [1].These negative experiences during labour have been proven to create a barrier for seeking both facility-based childbirth and postnatal health care, as well as increasing fear of childbirth and severe postpartum depression among the women who experienced them [2,3].This is not only a quality-of-care issue, but also constitutes a serious violation of human rights.Every woman has the right to the highest attainable level of health, including the right to respectful health care during pregnancy and labour, as stated by the Assertion of Universal Rights of Childbearing Women [4].
It is important to note that these behaviours by healthcare providers are by definition not intentional and may overlap with other respectful care practices.Nevertheless, women's experiences of D&A should be considered as such regardless of intentionality.In addition, the characteristics of the healthcare system may explain some of these negative experiences, but should not be used as justification for this mistreatment of women [5].
Many of the evaluations of D&A during childbirth were initially carried out in low-resource settings.Systematic reviews and meta-analysis in Africa and India have estimated its prevalence at 44% and 71%, respectively [6,7].However, childbearing women from middle and high-resource countries have also reported mistreatment and D&A during labour.In Latin America, two national surveys in Mexico and Ecuador have described prevalence rates higher than 30% [8,9].Similar research in the U.S. has reported results over 17% [10], ranging up to 27%-54% in the Netherlands [11,12], and 38%-67% in Spain [13,14].However, it is not possible to compare these prevalence studies, as different definitions are used to assess D&A in each of them.
The need for standardised typology and operational definitions of this phenomenon impedes wider research in this area [5].In 2010, Bowser and Hill reported seven types of disrespectful and abusive practices during childbirth: physical abuse, non-consented care, nonconfidential care, non-dignified care, discrimination, abandonment, and detention in health facilities [15].In 2015, Bohren et al. suggested the term "mistreatment of women", since they believed it to be broader and more inclusive for the complete range of negative experiences described in the literature.In their systematic review, they also proposed a new categorisation system: physical abuse, sexual abuse, verbal abuse, stigma and discrimination, failure to meet professional standards of care, poor rapport between women and providers, and health system conditions and constraints [5].
In Latin America, discussions have not focused on D&A, but rather on terminology referring to "obstetric violence" as one of the various types of violence against women [16].
Gender inequalities have been fundamental to the conceptualisation of this term.In this regard, Nagle et al. observed a significant relationship between structural sexism and C-section rates in the U.S. [17].This finding is in line with the theoretical framing that categorizes it as being a symptom of structural violence and sexism towards women.
Sadler et al. proposed that obstetric violence as a term could address these structural determinants of violence.One reason why this term is not more widely used is that healthcare providers are resistant to the use of the concept of violence [18].Focusing the debate on individual malpractices can give rise to unproductive hostility, which is why it is a priority to avoid blaming health professionals as a group [19].With this in mind, we will refer to these negative experiences of childbirth using the terms noted above (mistreatment and D&A) and avoid using the term obstetric violence.
Based on the principle that the absence of D&A alone is not enough, respectful maternity care (RMC) is an alternative approach which also highlights the rights of women, promotes equitable access to evidence-based practices and recognises the unique needs and preferences of women.This initiative has been recommended by the WHO as an approach to care for a positive childbirth experience [20].
Shakibazadeh et al. described some of the concepts that constitute RMC [21].Jolivet et al. operationalised these concepts into seven human rights-based categories of RMC: the right to be free from harm and ill treatment; the right to dignity and respect; the right to information, informed consent and respect for choices and preferences (including the right to companionship of choice wherever possible); the right to privacy and confidentiality; the right to non-discrimination, equality and equitable care; the right to timely healthcare and to the highest attainable level of health; and the right to liberty, autonomy, self-determination and freedom from coercion [22].Both respectful and disrespectful care should be taken into account, given that some practices may not seem very disrespectful but should not be considered acceptable as part of respectful maternity care [23].
Women's healthcare should be based on the best available scientific evidence, subject to systematic review and adapted to each patient's preferences, respecting their rights and principles.This evidence-based approach supports safe, effective and individualised care, while avoiding inappropriate or unnecessarily risky interventions that do not benefit women´s health [24].
Identifying successful interventions that have addressed these negative experiences during childbirth or that have been directed towards improving RMC may help to design and implement interventions based on best practice in other maternity services and countries.The aim of this article is to summarise the available evidence regarding the initiatives that have been taken to eradicate the mistreatment and D&A that women undergo during childbirth and to promote RMC in health facilities worldwide.

Study design
We conducted a descriptive scoping review of the available peer-reviewed literature.We followed the Arksey and O'Malley's five-stage framework [25].Research was conducted to answer the following question: What interventions have been proven as effective to reduce mistreatment, D&A during facility-based childbirth?

Search strategy
To identify relevant articles, published literature was searched in PubMed using Mesh and free-text terms referring to two main concepts: mistreatment of women and obstetrics.
The "Abstract" search filter was used (see "Eligibility Criteria").
No year restrictions were applied.Any article published previously to the date of the search was included in the review.The search was conducted on June 7, 2022.

Eligibility criteria
We selected any original study that assessed the effectiveness of interventions specifically designed to reduce experiences of mistreatment and D&A or to promote RMC during facility-based childbirth.Both clinical and institutional interventions were included.
The concepts mistreatment and D&A were considered inherently as presented in the original studies that proposed these two terms, as detailed in the introduction.
Articles were selected in English, Spanish, French, Portuguese and Italian.
Articles without an abstract were excluded.We also discarded studies whose methodology was not explicitly detailed (study protocols, commentaries, and conferences).
According to the definition stated before, these negative experiences of care would also encompass medicalization of childbirth.This includes unnecessary C-sections and similar procedures.Nevertheless, the problem on these avoidable medical interventions was recognised decades before research started to focus on mistreatment and D&A as a continuum.Consequently, a large body of literature has been published to this respect, which will require specific reviews on this subject.Moreover, most of the studies regarding this question lack the mistreatment lens when analyzing this issue.For these reasons, articles that only evaluated initiatives to reduce unnecessary C-sections and comparable medical interventions were also excluded.
A particular case are the studies that exclusively analysed programs on the presence of a companion of choice during labor.We also discarded these articles in order not to interfere with the overall scope of the review, since these only evaluated the change on some concrete firstorder theme.

Study selection
The three authors participated in the study selection.Each abstract was screened by two different researchers.The same procedure was followed for the full-text evaluation, so that every article was selected by two researchers independently.Discrepancies during these two stages were discussed with the third author until consensus was reached.

Data extraction
The following data were extracted: study type; target and objectives of the intervention (reducing mistreatment and D&A, increasing RMC); approach (quality of care, human rights, gender violence); description and scope of the intervention; evaluation methods; outcomes; and limitations and conclusion of the articles.
The selection of articles and data extraction were performed independently by two authors.Any discrepancies were resolved by consensus.

Results
The initial search yielded 2,279 citations.After screening for their titles and abstract, 40 studies remained.Concordance reached 90%.
After discussion, 15 additional articles were excluded.In case of any doubt, the article was considered for full-text analysis, prioritising the sensitivity of the search.Of the 25 articles that went through full-text analysis, 10 studies were finally included.No article was excluded for language reasons.This whole process is represented on Fig. 1.
The publication years ranged from 2015 to 2022, and all were located in Africa except for two, whose settings were Mexico [26] and the United States [27].
Of these 10 articles that were included, 5 did a before-and-after study [28][29][30][31][32], 3 used mixed-methods [26,33,34], one was a comparative study between birth centers [27], and another a quasi-experimental study [35].Three of them focused on reducing D&A, and 5 on increasing RMC.One sought birth racial equity [27], and another aimed at humanised childbirth [33].Every study approached this phenomenon as a qualityof-care issue, but only 5 of them addressed this topic from a human rights perspective (apart from the one approaching it as an ethnic disparity).Table 1 summarises the main characteristics of these articles.
Most of the interventions were conducted at facility level with different action plans, none of the articles was designed as a policy or as a community-level approach.

Fig. 1 PRISMA flowchart of search and study inclusion process
The article by Almanza et al. did not assess a concrete intervention but a comparison between Roots (a Blackowned culturally centred birth clinic) and other centers [27].More detailed information about the studied interventions and the way they were evaluated is presented at Table 2.
All the studies concluded that the implemented intervention resulted in an improvement in the care received by the delivering women.Kujawski [28], and Asefa et al. found an 18% reduction in the number of experienced mistreatment components [30].Afulani et al. observed a RMC increase from 12 to 64%, although their results differed from the other studies in that verbal and physical abuse paradoxically increased (despite the improvement in reports of being treated with respect) [29].
Oosthuizen et al. documented that different RMC components improved with the intervention [32], Molina et al. reported that satisfaction and the perceived quality of care improved [26], and for Gélinas et al. it was the way in which women were received at the health facility and the attitude of health professionals that were decisive for this level of satisfaction with care [33].
Ratcliffe et al. found that there was an increase in patient and provider knowledge of user rights, as well as women's knowledge of the labour and delivery process and provider's empathy for the women they served, with improved communication and user reports of satisfaction and perceptions of care quality [34].Almanza et al. described that autonomy and respect scores were statistically higher for clients receiving culturally centered care at Roots, but no statistical significance was found in scores between black, indigenous and people of colour, and white clients [27].More detailed results are presented at Table 2.

Discussion
This scoping review synthetised 10 articles testing any kind of initiative specifically designed to reduce D&A or to promote RMC for women seeking care during childbirth in health facilities around the world.Women who gave birth post-intervention appreciated their experience due to changes such as the opportunity to eat and drink, to be accompanied by a trusted person and to choose their position during childbirth.It was the way in which women received at the health facility and the attitude of health professionals that were decisive in their level of satisfaction with care  Our indicate that there are promising interventions to tackle this phenomenon.Even though it was a small sample of articles and in some cases the improvements were not extraordinary, they were sufficiently encouraging to implement context-specific programmes, to make the step from explanatory research to intervention and implementability.
Only 10 articles met the eligibility criteria.This points to a lack of evidence regarding initiatives specifically designed to tackle this phenomenon.Most of the efforts so far have been directed at determining the frequency of D&A and debating its terminology.This is especially relevant in high-income countries, as illustrated by the fact that all the interventions were studied in Africa, with the exceptions of Mexico [26] and the United States [27].
As noted before, childbearing women from middle and high-resource countries have also reported mistreatment and D&A during hospital births [8][9][10][11][12][13][14].Although the evidence presented by this article can be of value for these higher-income settings, it is important to acknowledge that in many African countries or other developing nations, women's social status is very low, they have less access to information and education, and live in very closed patriarchal societies, making them a vulnerable population.Therefore, investment on this type of approach could have a different impact in women's lives in this context.Nevertheless, this should not restrain high and middle-income countries from implementing similar initiatives to the described in this study, since women in these higher-resource settings could also benefit from reducing mistreatment, D&A during childbirth and promoting RMC.
Most of the articles reviewed included training as a relevant part of the intervention.Every study that did so, concluded that it resulted in an improvement of the care received by the delivering women [26,[28][29][30][32][33][34][35].Physical abuse was the most consistently reduced [28,30,31].These results suggest that provider education should include a form of RMC training, which should be encouraged by Gynecology and Obstetrics services.
In the case of Afulani et al. their results differed from the other studies in that verbal and physical abuse paradoxically increased (despite the improvement in reports of being treated with respect).A potential reason they found was that, while treating women with dignity and respect was emphasised in the training, verbal and physical abuse never actually occurred in their simulations, not giving a chance for improvement [29].Relative to this, specific types of provider training should be assessed by further scientific research.
Effort should also be headed towards finding any other kind of tools that could complement or enhance these trainings when implemented.Other strategies that only a few articles explored included open maternity days [28,34], clinical checklists [26], wall posters [30], and constant user feedback [28,31,32,35].While only tested by 1-4 studies each, every one of them seemed to complement the training effectively.
Most of the interventions addressed this issue from a RMC approach [26,29,30,32,35], especially apart from the ones centred on reducing mistreatment and D&A directly.This suggests that RMC constitutes the main initiative currently addressing women experiences of care during childbirth.
In the case of Asefa et al. although physical abuse was indeed reduced, no change was observed in the level of verbal abuse and neglect and discrimination, pointing to the fact that ingrained negative and normalised behaviours require time to change and are strongly associated with age and experience of service providers [30].
Evidence shows that women's healthcare is profoundly influenced by sociocultural factors and entrenched gender norms.Health providers often incorporate their own beliefs and biases into their practices, which shape the care they deliver.Addressing these problems requires not only changing the attitudes of health professionals, but also confronting the broader sociocultural beliefs prevalent within communities.Without challenging and transforming these ingrained norms, efforts to improve women's healthcare will continue to face significant obstacles [36,37].
Relative to this, all the interventions were carried out at facility level, without directly addressing the structural determinants of health related to gender-discrimination at policy level, which although difficult to achieve, could potentially be more effective [16,17].Besides, efforts directed towards designing community level interventions should also be made.
Our results are similar to those described by Downe et al.In their systematic review [38], they analysed the articles by Abuya et al. [28], Kujawski et al. [31] and Ratcliffe et al. [34], and two other studies (one placed in South Africa only assessing birth companions, and another one in Sudan testing a communication-building package with staff ).They found that RMC interventions increased women's experiences of respectful care by almost four times, and reduced D&A by about twothirds.In terms of specific attitudes and behaviours, they found that RMC initiatives could reduce physical abuse, with less evidence on other components of D&A.These results coincide with the ones presented in our study.
The articles included in our review shared several limitations.Most of them lacked a control group, which removed the ability to properly distinguish the intervention's effect from other contextual factors during the implementation period.In addition, the majority of the initiatives were (one took place during a year and a half [28], but the rest only lasted for a few months).Added to the fact noted before, that ingrained negative and normalised behaviours require time to change, this could have underestimated the potential effects of the interventions, but it also made it impossible to assess their long-term sustainability.Finally, for the articles that interviewed women as a means of intervention evaluation, social desirability and recall bias could have altered the results, and studies that included direct labour observations could have also been influenced by the Hawthorne effect (as observed providers may have acted more self-consciously).
Our study also has its own limitations.Being a scoping review, it lacked the degree of control that a systematic review could have offered.However, we felt that this allowed us to explore further findings, serving as a useful landscape analysis.PubMed was the only search engine screened, and we only considered articles with an abstract.Furthermore, given the changing terminology regarding this topic, a standardised search formula could not be used, which might have left some studies out of our scope.Nevertheless, we consider that most of the available evidence was reviewed within this article, providing a comprehensive approach regarding interventions to address this issue.

Conclusion
The 10 articles reviewed in this study indicate that there are promising interventions to reduce D&A and promote RMC for women during facility-based childbirth.Provider training is the most proven strategy, and physical abuse the most consistently reduced.The specific types of training and different initiatives that complement them should be evaluated through further scientific research, and RMC interventions that apply these strategies should be implemented by health institutions.Beyond the need for further research and implementation of the actions already examined, there is an urgent need to establish and evaluate more structural interventions and policies, in order to modify the social and health contexts that impede full RMC to ensure a human rights-based maternity care for women giving birth in health facilities around the world.

Table 1
Summary characteristics of the studies that described RMC interventions RMC respectful maternity care, D&A disrespect and abuse

Table 2
Interventions and results of the studies that described RMC interventions

Table 2
(continued)RMC respectful maternity care, D&A disrespect and abuse, OR odds ratio, Roots black-owned culturally centred birth clinic, BIPOC black indigenous and people of colour, GVtM giving voice to mothers study